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What Determines Successful Implementation of Inpatient Information Technology Systems?

Joanne Spetz, PhD; James F. Burgess, Jr, PhD; and Ciaran S. Phibbs, PhD
This paper reports findings from a qualitative analysis of US Department of Veterans Affairs hospitals on factors affecting success in implementing 2 information technology systems.
Objectives: To identify the factors and strategies that were associated with successful implementation of hospital-based information technology (IT) systems in US Department of Veterans Affairs (VA) hospitals, and how these might apply to other hospitals.


Study Design: Qualitative analysis of 118 interviews conducted at 7 VA hospitals. The study focused on the inpatient setting, where nurses are the main patient-care providers; thus, the research emphasized the impact of Computerized Patient Record System and Bar Code Medication Administration on nurses. Hospitals were selected to represent a range of IT implementation dates, facility sizes, and geography. The subjects included nurses, pharmacists, physicians, IT staff, and managers. Interviews were guided by a semi-structured interview protocol, and a thematic analysis was conducted, with initial codes drawn from the content of the interview guides. Additional themes were proposed as the coding was conducted.


Results: Five broad themes arose as factors which affected the process and success of implementation: (1) organizational stability and implementation team leadership, (2) implementation timelines, (3) equipment availability and reliability, (4) staff training, and (5) changes in work fl ow.


Conclusions: Overall IT implementation success in the VA depended on: (1) whether there was support for change from both leaders and staff, (2) development of a gradual and flexible implementation approach, (3) allocation of adequate resources for equipment and infrastructure, hands-on support, and deployment of additional staff, and (4) how the implementation team planned for setbacks, and continued the process to achieve success. Problems that developed in the early stages of implementation tended to become persistent, and poor implementation can lead to patient harm.


(Am J Manag Care. 2012;18(3):157-162)
The information technology (IT) implementation experience of a large diverse system, like the US Department of Veterans Affairs (VA), which has a mix of rural, urban, teaching, and community hospitals, provides valuable information about the issues surrounding implementation for hospitals in the private sector. IT implementation success in the VA depended on:

  • Whether there was support for change from both leaders and staff.

  •  Development of a gradual and fl exible implementation approach.

  •  Allocation of adequate resources for equipment and infrastructure, hands-on support, and deployment of additional staff.

  •  How the implementation team planned for setbacks, and continued the process to achieve success.
Computerized patient records and bar-code medication systems continue to gain favor in healthcare.1-5 In the hospital setting, 2 of the most important technologies are computerized patient records and medication administration systems.1,5,6 These systems are expected to bring about improvements in patient safety, work processes, and staff morale,6-11 and reduce rates of medication errors. 12-14 Research to date has reached mixed conclusions as to whether such improvements have occurred.10,11,15-24 Several studies demonstrate that the implementation process for hospital health information technology (HIT) is important to determining overall success.24-28

The US Department of Veterans Affairs (VA) has made one of the largest investments in HIT in the United States, implementing a fully integrated system across its 162 hospitals nationwide.28,29 The VA is the nation’s largest integrated healthcare system, with more than 7.2 million veterans enrolled for health services.30 Their development of an HIT system can be traced to the 1970s. The VA’s Computerized Patient Record System (CPRS) and Bar Code Medication Administration (BCMA) are central to inpatient care.28,29 CPRS was phased in over a decade starting in the early 1990s, and consists of a comprehensive electronic patient medical record with computerized physician ordering, covering both outpatient and inpatient services. By 2002, all VA hospitals had implemented CPRS; the vast majority had implemented this system by 2000. BCMA, on the other hand, was implemented over a much shorter time period, with VA headquarters requiring implementation 1 year after the software became available.29 This system created a computerized pharmacy ordering, distribution, and administration system for use in the inpatient setting. Bedside scanning of patient identifi cation wristbands and medications was the key component of the system, providing validation that each medication matched the orders for each patient.

This paper reports the findings from the qualitative component of a national, retrospective, mixed-methods study of the implementation of CPRS and BCMA. There were no prospective systemwide or multisite evaluations of the implementation of CPRS or BCMA. The study focused on the inpatient setting, where nurses are the main patient care providers; thus, the research emphasized the impact of CPRS and BCMA on nurses. The qualitative portion of the study focused on 4 issues: (1) understanding the approaches used to implement the VA’s HIT systems, (2) identifying factors that affected the process of implementation, (3) ascertaining the issues that determined success of implementation, and (4) understanding what nursing staff and leaders believe are the current strengths and weaknesses of CPRS and BCMA. The experience of a large diverse system like the VA, which has a mix of rural, urban, teaching, and community hospitals, provides valuable information about the issues surrounding information system implementation for hospitals in the private sector.

METHODS

We conducted site visits at 7 VA hospitals selected to represent a range of implementation timelines, geography, and staff characteristics. All site visits were conducted after receiving approval from each facility’s Institutional Review Board (IRB), as well as the IRBs of the University of California, San Francisco, Stanford University, and the Boston VA Healthcare System.

In advance of site visits, an Advisory Committee was assembled, consisting of VA medical, pharmacy, and nursing leaders, as well as representatives of the VA headquarters. The committee was asked to identify issues and themes that they anticipated to be important to understanding the impact of the implementation and use of the VA’s HIT systems on nurses. A semi-structured interview guide was developed after this meeting, based on a review of the literature on technology implementation and the effects of IT systems, and the committee’s suggestions. The committee members provided feedback regarding the content of the guide. This guide was used both to conduct the interviews and provide themes for the initial coding of the data. The guide is available in eAppendix A at www.ajmc.com.

Site selection was based on a unique Web-based survey of VA facilities documenting when each major component of CPRS and BCMA was implemented, VA staff satisfaction survey data, facility-level staff turnover data, geography, and the level of care provided by each VA hospital. We initially identifi ed 27 facilities that represented a range of characteristics, and then consulted with the Advisory Committee and the VA Headquarters Nursing Offi ce to recruit a final set of 7 facilities.

A total of 118 interviews were conducted over a 15-month period (June 2006 through September 2007) with nurses, pharmacists, nurse managers, information technology staff, and senior management. At most sites, physicians were not included because the study’s focus was inpatient IT systems, which are primarily used by nurses. Interview subjects were selected by site coordinators, who were recommended by members of the Advisory Committee and/or the VA Headquarters Nursing Offi ce, and were employees of the VA facilities. The principal investigator (PI) provided the site coordinators with a detailed list of the job classifications of the people to be interviewed (see eAppendix B at www.ajmc.com for categorizations and counts of the interview subjects). Interviews lasted 30 to 60 minutes and were held in private meeting and conference rooms, using the semi-structured interview protocol. Notes were taken by the investigators and were entered into ATLAS.ti to facilitate analysis after the site visit was complete.

A thematic analysis was conducted with initial codes drawn from the content of the interview guides. Additional themes were proposed as the coding was conducted and were added if there was concurrence among members of the research team. All coding was completed by the PI, while other members of the research team reviewed codes of 1 to 2 interviews per site. Investigators who visited each site reviewed the themes identifi ed from that site’s interviews.

RESULTS

Staff and managers faced numerous challenges while CPRS and BCMA were being implemented. As one VA employee stated, these IT systems changed “how we organize, document, and communicate regarding patient care,” changes that touched all aspects of healthcare delivery. The all-encompassing scope of IT implementation led to what another staff member described as “a big culture change.” This process of change can be tumultuous. A number of staff and managers used terms such as “frightened,” “nervous,” and “scary” to describe how nurses felt about CPRS and BCMA at first; one manager said there was “reluctance by many staff members to truly embrace the system, see the opportunities.” Another manager said, “a lot of clinical staff thought if they didn’t use CPRS it would go away.” The most resistant nurses and physicians reportedly left the VA through retirement or turnover.

Managers and staff agreed that employees who were not “tech savvy” had more diffi culty adapting to HIT; one manager noted that “less computer-skilled nurses struggle more.” Another manager observed that “some staff didn’t know how to use computers or mice,” which hampered their training. Many managers also noted that clinicians “tend to have weak keyboarding skills” because their jobs did not normally require much typing. At some sites, managers reported that older nurses were less likely to be comfortable with computers.

Five themes arose as important infl uencers of the process and success of implementation: (1) organizational stability and implementation team leadership, (2) implementation timelines, (3) equipment availability and reliability, (4) staff training, and (5) changes in work fl ow.

Organizational Stability and Implementation Team Leadership

The broader culture of the facility fundamentally affected the success at each site. One VA employee said, in a “large organizational deployment, [the organization] needs [to be] very stable and fault-tolerant… In planning, [you] have to have good leadership to articulate the nursing position.” Sites with unsupportive management teams, or where staff did not respect the ability of management, faced more challenges both during and after implementation of BCMA and CPRS. Managers often set the tone for how their departments or staff accepted HIT. As one leader noted, “if nurse managers were in support, you could get a lot farther.”

The teams that led the CPRS and BCMA implementations were crucial to success. For CPRS, the medical staff was usually viewed as most important, at least in part because CPRS has a central role in the outpatient setting. At every site we visited, staff and leadership recognized that nursing involvement in the BCMA implementation was crucial, and that pharmacy and IT staff had to be partners in the process. As one manager said, “success is all about teamwork.”

At some sites, the responsibility of implementation was not accepted by all parts of the team. For example, at 2 sites, pharmacists thought BCMA was primarily a nursing program, and thus “meetings didn’t go anywhere.” These sites had more diffi culty, because problems were not addressed in a cohesive way. Several staff members and managers noted that implementation of both systems required involvement of end users; sites that had physicians and staff nurses in visible roles during implementation achieved buy-in from other care providers more easily.

Implementation Timelines

Flexibility in implementation helped staff adapt to CPRS and BCMA, regardless of how the implementation was specifically planned. CPRS evolved over time, with its antecedents developed in the early 1980s. There was no implementation deadline for CPRS, and most VA facilities used a gradual unitby- unit rollout to implement CPRS. One nurse noted that, at her site, “not much prep work was done before implementation, but that was somewhat okay because it was phased in.”

In contrast, the implementation of BCMA was mandated by VA headquarters with a June 30, 2000, deadline, which was only 1 year after the software was made available. The short timeline for BCMA implementation made staff feel pressured to use a system that they perceived had fl aws. One staff member argued “the software wasn’t ready, and the hardware had not been researched,” making it a “big mistake” to require implementation at that time. Some sites introduced BCMA in departments with relatively stable patient populations, such as in the long-term care ward. Other sites selected psychiatric units for the initial implementation, because patients go to a specifi c desk to receive their medications. In these wards, mobile carts and wireless scanners were not needed to operate BCMA, thus reducing the complexity of the implementation. These approaches seemed to work well because they gave the implementation team the opportunity to gain experience with the system in a controlled environment.

Equipment Availability and Reliability

 
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